Long Term Care Application - Christopher House

X/Twitter

This field is for validation purposes and should be left unchanged.

PERSONAL INFORMATION

First Name*

Middle Name

Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Number*

Cell Number

Date of Birth*

MM slash DD slash YYYY

Have you served in the U.S. armed forces?*

Yes

If Yes, provide Years of Service:

From

Are you a U.S. citizen?*

Yes

Sex*

Male

Female

Marital Status*

Married

Single

Widowed

Divorced

Separated

Name of Spouse

Religion

Highest Level of Education

Occupation

Hobbies or Club Associations

Year Retired

FINANCIAL MANAGER

PLEASE STATE THE NAME(S) OF ANY PERSON(S) THAT HANDLE FINANCIAL MATTERS

Name

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Mobile Phone

Work Phone

Is there a Power of Attorney?

Yes

Please provide their name

Phone

Upload a copy of the power of attorney here

Drop files here or

Max. file size: 512 MB.

Please check type of authority

Representative Payee

Conservator

Legal Guardian

Durable Power of Attorney

Type: Irrevocable Trust/Bank Account

Yes

Funeral Home

Contact Name

Address

Phone

HEALTH CARE PROXY

Please upload a copy here

Max. file size: 512 MB.

Name

Phone

Relationship

Address

Is there a Legal Guardian

Yes

Name of Legal Guardian

Spokesperson for the Applicant

Name

Phone

Emergency Contact 1

Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relationship

Cell Phone

Home Phone

Add an Emergency Contact Here

Health Insurance and Income

Medicare #

Type of Medicare

Part A

Part B

Part D

Part A&B

Other Health Insurance You May Have

Please Provide a Copy of Your Insurance Card with this Application

Max. file size: 512 MB.

Name

Policy Number

Are the Premiums Quarterly or Monthly?

Monthly

Quarterly

Amount

Social Security

Recipient Name

Monthly Income

Retirement (Pension)

Recipient Name

Monthly Income

VA Pension

Recipient Name

Monthly Income

Rental Incomes

Recipient Name

Monthly Income

Annuities

Recipient Name

Monthly Income

Other

Name

Recipient Name

Monthly Income

Please Note: If you are Applying for Mass health (Medicaid), The look back period is 5 (five) years. This is to determine whether there have been any disqualifying assets transfers.

Bank Accounts

Bank Name

Account #

Names on the Account

Type

Balance

Add Another Bank Account Here

Life Insurance

Policy 1

Company Name

Beneficiary

Policy #

Face Value

Add Another Insurance Plan Here

Current Living Situation

Does the Applicant Live Alone?*

Yes

With Whom Do They Live?

Address

Contact Person

Telephone #

Physician

Telephone #

Does the Applicant Need Help? (Check All that Apply)*

Eating

Bathing

Getting Dressed

Does not Need Help

Does the Applicant have memory loss?*

Yes

What kind?

Short Team

Long Term

Both

Does the Applicant Walk? (Check All that Apply)*

Independent

Uses Cane

Uses Wheelchair

Is the Applicant Incontinent? (Check All that Apply)*

Bladder

Bowel

Not Incontinent

Has the Applicant been diagnosed With Alzhimer's/Dementia?*

Yes

Does the Applicant Have Any Behaviors that Are of Concern?*

Yes

Please List Them Here

Applicant's Physician*

Address*

Telephone #*

Has the Applicant Been Hospitalized Recently?*

Yes

Hospital

Approx. Date

MM slash DD slash YYYY

Please Provide Date of Last Physical Exam

MM slash DD slash YYYY

Has Applicant Ever Been Admitted To A Nursing Home?*

Yes

Name

Address

Date

MM slash DD slash YYYY

Has Applicant Ever Been Admitted To A State Hospital or Psychiatric Unit?*

Yes

Name

Address

Date

MM slash DD slash YYYY

Alcohol and Tobacco Usage

Alcohol Use*

Yes

How often?

Past

Present

Past and Present

Tobacco Use*

Yes

How often?

Past

Present

Past and Present

Application Completed By*

Date*

MM slash DD slash YYYY

CAPTCHA